Provider Demographics
NPI:1245905538
Name:RYAN, KELLY A (LPC, LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:RYAN
Suffix:
Gender:F
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 WESSEX WAY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-6436
Mailing Address - Country:US
Mailing Address - Phone:512-769-9845
Mailing Address - Fax:
Practice Address - Street 1:903 WESSEX WAY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6436
Practice Address - Country:US
Practice Address - Phone:512-769-9845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203247106H00000X
TX79354101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist